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Information Technology Edward H. Shoreline I should acknowledge that you didn't see my name on the list as a member of the committee because I couldn't be at Woods Hole. However, I had the pleasure of being here the night of the initial dinner and subse- quently on phone conversations as we put together some of the recom- mendations you are hearing tonight. I will be talking about the information technology piece, which al- though we separated it out as a topic, is also integrated across the other categories because it is an enabler for so many of the activities we wish to pursue in the modern world. It just becomes an obvious and important part of the mechanism by which some of these experimental plans can be effective. I would point out that if you take the six major goals outlined in the Crossing the Quality Chasm report, there are clear relationships through the information technology agenda for all six. For example, in safety, many people have pointed to the importance of information technology and ad- dressing issues related to medication errors during order entry safety checks. Effectiveness can be enhanced by a reminder of alerts and other mechanisms that can make you more effective. The increasing uses of the Internet and other information resources aimed at patients have allowed us to be more patient-centered in the care that we provide today. The timeliness issues are associated with rapid access to information through computer interfaces that replace, for example, the paper reports 12

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INFORMATION TECHNOLOGY 13 that we used to wait for. There are other efficiency issues along those lines and even equity issues. For example, we have the ability to use computer- based Internet facilities for maximizing enrollment for indigent individu- als in state health plans and the like. I might add to the six goals from the Quality Chasm report the obvious relevance of information technology in supporting national security through the public health infrastructure and responses to bioterrorism and other public health hazards. We are suggesting a series of demonstrations with the objective of really showing we can establish state-of-the-art infrastructure in an entire geographic region, or at least in a state or a significant large metropolitan area of a state. We would also like to demonstrate the ways in which the technology, when properly implemented, can support communication among providers, patients, the various organizations that are in public health in that region to enhance access to patient data, to manage knowl- edge more effectively, and then to provide enhancements to decision mak- ing. We proposed 8 to 10 sites spread geographically across the country because the issues that arise really do differ as you go from one part of the United States to another. Also, the degree of experience and sophistica- tion is not uniform across the different regions of the country. This, it seemed to us, should come straight from the department with a Request for Proposals (REP), requesting responses from investigators and com- munities that wish to address these discrepancies and to develop these types of demonstration projects. We thought it would take about five years for them to come to frui- tion and, again, this would be one time only, up-front federal funding with the goal being to have this infrastructure continue in a self-supported fashion. The three phases would start with a planning period of about six months, during which the coming together of the public and private par- ticipants in a region would be required. We are talking about providers, but also city and state governments, departments of public health, both in cities and statewide, patient groups, payers, all of whom need to be part of these kinds of experiments for them to be maximally effective. That also means that once you get them together, the next step would involve developing a detailed operational plan. At the end of the second phase, which would continue from about the sixth month through the second year, you need to create the underlying infrastructure. This would be a similar kind of challenge for everyone within the demonstration projects, I believe. You need to establish connectivity for the providers and for other us- ers in the community and create a kind of portal mechanism that is se-

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4 FOSTERING RAPID ADVANCES IN HEALTH CARE cure, maintains confidentiality, and allows the exchange of data that would be necessary for the kind of experiments we envision. Such demonstrations can then build on top of this infrastructure, but you will notice you already have some tangible results after two years of effort with these types of projects. One of our goals was to have some- thing to show for the activity well before the five years was up. Then, in the third phase, there is the development of a comprehensive information and communications technology infrastructure. Again, you need to build on computer-based patient records, which occurred in some of the other comments you have already heard. In fact, you could imagine joint demonstrations in this area and chronic care, for example, or in the primary care effort. Then other kinds of applications and here we probably see differen- tiation across the regions, where they would choose to emphasize some applications more than others, but you notice a range of suggested areas in which there is ample opportunity for using this infrastructure to dem- onstrate the effectiveness of the technology and support of a new view of health care and health care delivery and health promotion.